Ellen N. La Motte

“ The private practitioner should be as well able to make a sure diagnosis as the municipal physician. He should be as ready to report the case. The private practitioner should be as capable a teacher, as careful a distributor of supplies, as alive to the danger of tuberculosis as the municipal nurse. The only difference between these two groups of people is that one acts and the other does not—or acts in such intermittent and irregular manner as to be productive of no results. ”

“ In the first place, tuberculosis is largely a disease of the poor—of those on or below the poverty line. We must further realize that there are two sorts of poor people—not only those financially handicapped and so unable to control their environment, but those who are mentally and morally poor, and lack intelligence, will power, and self-control. The poor, from whatever cause, form a class whose environment is difficult to alter. And we must further realize that these patients are surrounded in their homes by people of their own kind—their families and friends—who are also poor. ”

“ Neither should a nurse fraternize with her patients. Through familiarity she loses the personal dignity which means so much to her authority. Authority is a term somewhat subtle in its definition—it means that hint of power, of sureness, of knowledge, which enables one to speak with a confidence which transmits itself to others, and compels them to accept one’s point of view. A strong personality easily conveys this sense of authority, but it may also be conveyed by a personality less strong, when the nurse is well assured of her facts and cannot be caught tripping. ”

“ If a Health Department is hampered by politics, either as a 277whole or in certain mismanaged branches or divisions, it is useless to expect results. Placed under such a handicap, tuberculosis work would fail. Not only would the taxpayers’ money be wasted, but the community would suffer through a false sense of security, gained through its faith in, or rather its ignorance concerning, a badly conducted department. To trifle with the health of a community is a criminal act, and a Health Department which is “in politics” is the most immoral of all corrupt city departments. ”

“ Among the very poor, where it is impossible to regulate living conditions, there is practically no doing away with the danger of infection.
Whenever the parents are sick, selfish, or ignorant; when the children are undisciplined and uncontrolled, and where the grind of poverty has reduced ethics to the most primitive basis, one cannot expect much. When a child is in constant contact with a tuberculous individual, no matter how careful that individual may try to be, there is always some danger. By the very nature of his disease, a consumptive cannot be a hundred per cent. ”

“ To concentrate on one’s specialty is all we should ask of anyone. Any social agency which scatters instead of concentrates, produces superficial work, which is open to well-deserved criticism. As well expect a nurse to become a kindergarten teacher, because she sees the need for kindergartens, or to become a playground teacher or settlement worker, as to take upon herself the rôle of charity-organization agent. ”

“ Furthermore, the community itself should not be daunted if the physicians as a body do not endorse the prospect of a tuberculosis nurse. This prejudice against public health nursing is the common experience in all cities where visiting work has been established, but it gradually wears off as the nurse is able to demonstrate her value. Little by little the doctors are won over, as they begin to realize that she is not a rival but an assistant. In Baltimore, our experience has been that those physicians who were at first our worst opponents have now become our staunchest and warmest friends. ”

“ The Prevention of Tuberculosis. The object of the nurse’s work is to prevent the spread of tuberculosis—it is not to cure the disease. In doing the preventive work, it often follows that the patient himself is immensely benefited, and his disease apparently arrested. This arrest, however, is incidental—it is not the real object of the work, which is the protection of individuals as yet uninfected. In no other branch of nursing is there so much misunderstanding, so much placing of the cart before the horse, and so much emphasis laid on the wrong thing. ”

“ There is one point which must always be brought out. It is not so much what the patient does with his working hours, as what he does with his leisure hours, which determines his ability to hold his own. An arrested case may work eight or ten hours a day, in office, factory, or shop, and still remain well, provided he spends the remaining hours of the twenty-four in a proper manner. The ex-sanatorium case, rejoicing in his apparently restored health and in his regained liberty, feels that he can resume life on exactly the same terms as before. ”

“ Let us first consider the nature of the disease. Tuberculosis is a prolonged, chronic disease, which may be drawn out over a period of months or years. The patient has many ups and downs, being sometimes so ill that he places himself under the care of a physician, sometimes so much better that he does not see a doctor for months. We have known patients who have not been to a physician for years, yet during that time they were infectious cases, as proved by sputum examination. During a hiatus of this kind, how can we possibly hold the doctor responsible for the tuberculous patient? ”

“ The lung tissue destroyed by tuberculosis can not be replaced or renewed any more than lost fingers can be renewed. Yet a lung, in spite of this loss, is still able to serve its owner well and enable him to lead a useful and happy life, just as a hand which has lost a finger or two may still be a fairly useful hand, and serve its owner well. This distinction between arrest and cure must be made perfectly clear to the patient, and he must also be taught that whether the arrest of the disease is temporary or permanent depends in large measure upon himself. ”

“ Failure in any one direction is felt down the line, consequently each is stimulated to its best effort. Thus, the nurse knows that if she fails to persuade her patient to enter the hospital, the hospital is useless, or that if the bad food of the hospital drives the patient back again to his home, the nurse’s work goes for nothing. Each reacts upon the other, and as all are working for the same end, there is constant incentive to become a strong, rather than a weak link in the chain. ”

“ In the first place, all physicians, no matter how well they may be trained, are not necessarily good teachers. No matter how keenly aware of the danger of tuberculosis, they are often unable to impress it upon their patients. Again, the busy physician has usually too little time to be a careful teacher. When conscious of a crowded waiting-room, or of the urgency of his next call, he is unable to give any but the most superficial and hurried instructions about the nature of tuberculosis, or the use of the prophylactic supplies. ”

“ In carrying out this important work, the nurse sometimes becomes so enthusiastic that her common-sense gives way under the strain. She wishes to carry her point, without fully realizing the prejudices, ignorances, sometimes even the comfort, of the family she is dealing with. After a death, she comes upon a household in a most upset, distressed, and often irresponsible condition, and she must be very gentle and patient in her relations with them. ”

“ The patient who refuses to go to an institution is probably no more dangerous than he who clamours in vain for a bed. The docile, well intentioned, kindly consumptive is doubtless as much a menace as the selfish, vicious, avowedly careless one ”

“ We all know that a week or two is not sufficient time in which to restore a thoroughly tired person; at the end of such a short period, one is just beginning to feel rested, and there has been no margin left over for amusement, which is a necessary part of all holidays.
Strong emphasis must be laid on the fact that if a nurse expects to return to her work and continue it successfully for another year, she should use this vacation as a means of fitting herself for another year’s close contact with an infectious disease. ”

“ It is better to say too little than too much, better to leave something unsaid until the next time, rather than overwhelm those she visits with a mass of advice which they cannot assimilate. Her first visit has been made as the bearer of distressing news, no matter how gently and carefully it may have been broken, and the distress and confusion which often arise fill the minds of her hearers to the exclusion of nearly everything else. ”

“ But it is not enough to tell the patient why he needs fresh air—the nurse must show him how to get it. He is singularly helpless and unable to recognize such ways for himself. Also she must overcome his objections and bring him to her way of thinking. Thus, he objects to his porch because it is shaky, or because it may only be reached by passing through another person’s room. Investigation may prove the shakiness imaginary, or at least not dangerous, while the other person may be only too willing to let his room be used as passageway to this desirable goal. ”

“ If a nurse calls on ten patients in a block, and finds none of them in, she naturally can make more visits than when compelled to spend a long time in each house. As in everything else, it is the quality that counts, rather than the quantity; the day which shows few visits may have been spent more profitably than that on which she scored a high total. There is no general rule as to a nurse’s capacity, yet it is always well to suspect the value of a large total of daily visits ”

“ The nurse is alone in her district all day long, from early morning till late in the afternoon, and she must be a woman with a high sense of responsibility and worthy of her trust. Patience, that despised virtue, is also an essential part of the nurse’s equipment, for she must listen to long details of illness, and must be willing to reiterate, over and over again, without show of annoyance, the rules which have been needlessly and exasperatingly ignored. ”

“ The qualities of a teacher are requisite. No matter how well one may know a subject, if one cannot present it clearly and impressively, small progress will be made. Nor is it the patient alone that the nurse is called upon to deal with. Her activities bring her into close relations with physicians, social workers, politicians, boards of directors, and “benevolent individuals” of all classes, whose interest and good-will it is necessary to secure. She must be as well able to meet people of this sort, as to teach the humblest patient in her district. ”

“ It is always the badly trained physician who fears the well-trained nurse.
Furthermore, there are certain practitioners who frankly exploit their patients. They may be competent enough but they are in medicine to make a living, and are often brutally unethical as to how this is done. If through self-interest it seem best to them to withhold from the patient the nature of his disease, they do not hesitate to do so, regardless of the danger to which others may be exposed. ”

“ Small wonder that the doctor forgets these patients—mere transients—and that, even if he has time to diagnose them, he does not consider himself their physician, or responsible for them in any way. It is for just such cases, however—those patients who come into fleeting and haphazard relation with their physician, that municipal control is required. It is no reflection upon the private practitioner that he has failed to make headway against tuberculosis. It simply proves that people with this disease must be watched and cared for by those who are able to devote their entire time to it. ”

“ In summer, a dress of washable material is not conspicuous. In winter, it may be covered with a long coat. And if we admit that such a dress is necessary, what objection can there be to making it of simple and uniform design? A single nurse so arrayed looks neat and business-like; a staff of nurses looks equally so. Moreover, uniformity of dress suggests uniformity of method, standard, and character of work, and hence inspires confidence. A staff of nurses, each one dressed according to the hazard of her own fancy, would hardly create the same impression. ”

“ We must never forget that the home is the chief centre of danger, the place responsible for the vast majority of infections, and that every infection which occurs outside the home is accidental, so to speak. Yet accidental infections, while relatively few in number, are still plentiful enough to make it necessary to safeguard the community in every way. An effective tuberculosis campaign demands the stoppage of all leaks. ”

“ When a nurse is visiting a case in charge of one doctor, she must be exceedingly careful never to advise another or to suggest a dispensary. All this involves infinite waste of time and loss of life, but as matters stand to-day, there is no other course to pursue. When a nurse is visiting a case of this kind—it may be one who presents every symptom of tuberculosis, including even hemorrhage—she must be particularly careful. ”

“ There is another class of practitioners, who, while willing enough, are nevertheless unable to contribute much towards the anti-tuberculosis campaign. These are the men whose education is limited, who are unable to recognize tuberculosis until it is advanced, and even then hesitate to commit themselves. The patient under these circumstances has ample opportunity to infect others, to say nothing of losing his own life into the bargain. No amount of conscientiousness, of integrity, and of honest intention can compensate for lack of skill. ”

“ The family should be taught the difference. Very harmful and indigestible are the products of the corner bakery, the penny candies, the enormous pickles, and the copious strong brews of tea and coffee which form so large a part of the dietary of those near the poverty line. Considerable money is spent on these things—often money enough to provide a wholesome meal, if the family but knew how to discriminate. In planning a patient’s diet, the nurse will have to do as much exclusive as inclusive propaganda. ”

“ What nurses are not trained to see, and what many of them have neither imagination nor faith enough to see, is the number of lives that are probably saved through the safeguarding of a dying individual. It has been said that the world would be infinitely better off if every consumptive in it could die to-day, since by this loss the people of to-morrow would be saved. The nurse must cease to reckon in terms of hundreds of patients—she must reckon in terms of the thousands who come in contact with these patients. ”

“ All these doubts and difficulties in connection with the diagnosis of tuberculosis in children serve to show that in a way this question may be called a negligible one, negligible, that is to say, as a menace to public health. It is important for the individual that a diagnosis be made, in order to do intensive work in upbuilding his resistance, but he is negligible as a distributor of infection. ”